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Volunteer Service Online Application - Marwood Nursing and Rehab

Marwood Nursing and Rehab|Documents and Links|Volunteer Service Online Application - Marwood Nursing and Rehab

Marwood Nursing & Rehab Volunteer Service Application

*Indicates required information

Contact Information

Last Name: *

First Name: *

Middle Initial:

Address *

City *

State *

Zip Code *

Home Phone Number: *

Cell Phone Number:

Which program are you interested in: *

Adult - 18 years and olderJunior - 14 - 18 years

How did you hear about us:

Emergency contact name: *

Emergency contact phone number: *

Education and Experience

High School - years completed: *

College - years completed:

College Major:

Junior Volunteers - Age 14 - 18

Are you volunteering to satisfy community service for a school or university: *

YesNo

If yes, please list number of hours needed:

What is the required completion date:

Are you currently employed: *

YesNo

If yes, please enter name of employer:

If yes, please enter employer address:

Previous Volunteer - Work Experience

Organization:

Dates of service:

Supervisor:

Duties:

Organization:

Dates of service:

Supervisor:

Duties:

Organization:

Dates of service:

Supervisor:

Duties:

Organization:

Dates of service:

Supervisor:

Duties:

Have you ever been convicted of a felony: *

YesNo

Are you volunteering to satisfy a court-required community service: *

YesNo

If yes, please enter number of hours needed:

Required completion date:

List probation officer name:

Probation officer phone number:

Availability

Please indicate the day(s) of the week that you are able to volunteer if the Volunteer Department accepts your application. Shift times vary according to assignment.

Indicate the days and times available: *

Monday DaysMonday AfternoonsMonday Evenings
Tuesday DaysTuesday AfternoonsTuesday Evenings
Wednesday DaysWednesday AfternoonsWednesday Evenings
Thursday DaysThursday AfternoonsThursday Evenings
Friday DaysFriday AfternoonsFriday Evenings
Saturday DaysSaturday AfternoonsSaturday Evenings
Sunday DaysSunday AfternoonsSunday Evenings

Are you willing to work holidays: *

YesNo

Position Desired

Direct patient contact: *

YesNo

First choice:

Second choice:

Special Skills/Interests/Hobbies

Language(s) including sign language - please specify:

Are you willing to serve as an interpreter:

Hobbies and special skills - please list:

References

Reference name:

Relationship:

Phone number:

Reference name:

Relationship:

Phone number:

I authorize an investigation of this application, agree to cooperate in such an investigation and release all liability or responsibility of all persons or entities requesting or supplying such information.

Marwood Nursing and Rehab offers equal opportunity to all based upon individual merit and without regard to race, color, religion, national origin, disability, age or gender. Marwood Nursing and Rehab is not obligated to provide placement nor is the applicant obligated to accept the volunteer position offered.

Signature - Applicant Name: *

Date: *

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